Doctor Training In IrelandMar 28, 2016 -
Author: Tony McNamara, CEO, Cork University Hospital Group
Much has been said and written in recent times about positive and negative aspects of the structure of post graduate doctor training in Ireland. I use the term doctor rather than the term junior doctor (which I believe to be pejorative) or NCHD because many doctors do not aspire to be hospital consultants but desire a career in General Practice or elsewhere. In any event as an observer of medical training and a non-medical practitioner (CEO at Cork University Hospital for nearly 25 years) I offer some observations as a contribution to this debate.
The traditional structure for post graduate medical training is based on the medieval model of the Master/Apprentice used to train sculptors, artists and the like in the Middle Ages. In the late 19th and early 20th Century post graduate medical education became centered around hospitals-pioneered by Sir William Osler and Dr. William S. Halsted. The model of residency programmes spread in the US and Europe and still exists today. Training at times involved extremely long hours of service and almost total commitment to training and career.
A number of very important questions come to mind regarding the Master/Apprentice model of which these are but a few;
- What does this relationship imply and what culture and behaviors does it almost universally promote?
- In a time where society through enacted legislation promotes values such as equality, dignity at work, respect for other team members etc. in the workplace does the Master / Apprentice model create the environment in which these values are fostered and practiced in doctor training?
- What does doctor training in this model and in this environment promote in terms of values that influence individual behaviors in training doctors in subsequent years?
The Master / Apprentice training model in it’s very essence explicitly promotes a deferential relationship between both parties. The “Apprentice” is dependent on the “Master” to cascade the professional skills needed to fulfill the requirements of the training bodies and to fulfill their employment obligations as employees. This dependence on the “Master” promotes subservience in the relationship which is unusual in most other sectors of employment today.
Furthermore the medical world in Ireland is a relatively small one in which practitioners (particularly at more senior levels) are known to each other. In this environment the matter of obtaining references is very important and this in itself places the graduate doctor in a difficult position.
Of course consultants in our multiple specialties in hospitals differ and to their credit most promote values of resepct, acknowledgement and unconditional support which is as it should be. However some do not and instead behave in a way that is counter to these values and in the process create a culture in which this is seen as normal and can be promoted in a way that it is acceptable which it is not.
There have been many recent drivers for change including the Medical Practitioners Act 2007, the European Working Time Directive and the Buttimer Report 2006 as well as the direction of the post graduate training bodies and colleges. In addition engagement with doctors in training at a hospital level has proven very beneficial and our own experience with the NCHD Forum at Cork University Hospital has produced a vibrant, enthusiastic forum with practical and deliverable initiatives on education, the work environment and staff rostering.
Having seen very many reports on the adequacy of training facilities in our hospitals I have yet to see any meaningful reference to the culture within which graduate doctors are being trained. Policies such as the HSE “Dignity at Work” provide a very important framework that set out behaviors that are acceptable and those that are not. We must, at every level, increase awareness of these standards and embed them in the culture of our hospitals to improve the work and training environment for doctors. It is a matter for leaders at all levels of hospitals, executive, clinical and academic coupled with those bodies charged with the responsibility of accrediting training to consistently emphasise what are and what are not acceptable behaviors.
The adoption of values of respect, dignity and equality into the training programmes in our hospital will properly demonstrate leadership support for doctors in post graduate training to whom we have a collective responsibility and for future generations of doctors who will deliver and lead the health services.
The Master / Apprenticeship model is most likely here to remain the training model for the foreseeable future but let’s work together to make it reflective of the societal values we espouse in 21st century Ireland.
Comments and feedback welcome. Thank you.